Petition for Change of Name (For Adult Individual) Page 1 of 4
Form CAFC401 04/2016 This form is available for free at www.selfrepresent.mo.gov
IN THE CIRCUIT COURT OF , MISSOURI
(County where court is located. City of St. Louis is considered a county.)
In re:
(First Name) (Middle Name) (Last Name) (Jr./Sr./III)
Petitioner
(Enter your full legal name above)
Case No.
(Will be assigned when case is filed)
Division No.
(Will be assigned when case is filed)
Petition for Change of Name (For Adult Individual)
Your Information (You are the “Petitioner” in this case)
1. My current full legal name is:
(First Name) (Middle Name) (Last Name) (Jr./Sr./III)
2. I want to change my name to:
(First Name) (Middle Name) (Last Name) (Jr./Sr./III)
3. Check one of the two boxes.
This is the first petition I have filed in this case. (Original Petition)
This is the second petition I have filed in this case.
4. My mailing address is:
(Street)
(City) (State)
(Zip)
(Telephone Number with Area Code) (E-mail Address - Optional)
5. My parent’s full legal name is:
(First Name) (Middle Name) (Maiden Name - if applicable) (Last Name) (Jr./Sr./III)
6. My other parent’s (father or mother) full legal name is:
(First Name) (Middle Name) (Maiden Name - if applicable) (Last Name) (Jr./Sr./III)
7. My husband’s or wife’s full legal name is:
(First Name) (Middle Name) (Last Name) (Jr./Sr./III)
eForms
Petition for Change of Name (For Adult Individual) Page 2 of 4
Form CAFC401 04/2016 This form is available for free at www.selfrepresent.mo.gov
8. My birth date is:
(mm/dd/yyyy)
9. My place of birth is:
(City) (State) (Country)
10. The change of my name would not be detrimental to any other person.
11.I want to change my name because:
12. I reside in
t
he United States another country, which is:
13. I reside in the State of
.
14. I reside in the County of .
15. Check one of the two boxes.
My name has never been changed.
My name has previously been changed as follows:
16. Check all boxes that apply.
I am the victim of a crime based upon domestic violence as defined in §455.010, RSMo.
I am the victim of child abuse as defined in §210.110, RSMo.
I am the victim of abuse by a family or household member as defined in §455.010, RSMo.
None of the above.
17. Check one of the two boxes.
There are no unsatisfied money judgments against me.
There are unsatisfied money judgments against me in the following cases:
State the name and number of the case in which the judgment was entered and the court in which the
judgment was entered.
State the name and number of the case in which the judgment was entered and the court in which the
judgment was entered.
Petition for Change of Name (For Adult Individual) Page 3 of 4
Form CAFC401 04/2016 This form is available for free at www.selfrepresent.mo.gov
18. Check one of the two boxes.
There are no cases requesting money pending against me.
The following cases in which money is requested are pending against me:
State the name and number of the case and the court in which it is pending.
Children’s Information
19. I have child(ren) who is/are listed below.
Enter the number of children above. Enter each child’s full name below as it appears on the birth certificate. Also state
the age and address of each child. If you have more than six children, attach an additional page.
a.
(F
irst Name) (Middle Name) (Last Name) (Jr./Sr./III) (Child’s Age)
(Street) (City) (State) (Zip)
b.
(First Name) (Middle Name) (Last Name) (Jr./Sr./III) (Child’s Age)
(Street) (City) (State) (Zip)
c.
(F
irst Name) (Middle Name) (Last Name) (Jr./Sr./III) (Child’s Age)
(Street) (City) (State) (Zip)
d.
(First Name) (Middle Name) (Last Name) (Jr./Sr./III) (Child’s Age)
(Street) (City) (State) (Zip)
e.
(First Name) (Middle Name) (Last Name) (Jr./Sr./III) (Child’s Age)
(Street) (City) (State) (Zip)
f.
(First Name) (Middle Name) (Last Name) (Jr./Sr./III) (Child’s Age)
(Street) (City) (State) (Zip)
Request for Relief
THEREFORE, I ask the court to change my name from the name stated in Paragraph 1 above to the
name stated in Paragraph 2 above.
Petition for Change of Name (For Adult Individual) Page 4 of 4
Form CAFC401 04/2016 This form is available for free at www.selfrepresent.mo.gov
Sign Below in the Presence of a Notary Public
Petitioner, of lawful age, being duly sworn on his or her oath, states that he or she is the petitioner named
above and that the facts stated in this Petition for Change of Name (For Adult Individual) are true according
to his or her best knowledge, information and belief.
(Sign above in the presence of a Notary Public) (Print your name above)
The following information must be completed by a notary public.
STATE OF )
) SS
COUNTY OF )
On this day of , 20 , before me personally appeared,
, to me known to be the person described in and
who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free
act and deed.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County and
State aforesaid, the day and year first above written.
, Notary Public
County, State of Missouri
My commission expires:
Attorney
Information
This information may be completed by your attorney. Do not enter any information here if you are filing this case without
the assistance of an attorney.
I have assisted Petitioner in the preparation of these pleadings, but I am not entering my
appearance on behalf of Petitioner.
(Attorney - Sign above) (Missouri Bar Number)
(Attorney - Print your name above)
(Street)
(City)
(State) (Zip)
(Telephone Number with Area Code) (Fax Number with Area Code) (E-mail Address - Optional)
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